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Clinical Summary

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These patients are most often young men (average age 16 to 17.5 years) who present complaining of the sudden onset of pain in one testicle. The pain is then followed by swelling of the affected testicle, reddening of the overlying scrotal skin, lower abdominal pain, nausea, and vomiting. An examination reveals a swollen, tender, retracted testicle that often lies in the horizontal plane (bell-clapper deformity). The spermatic cord is frequently swollen on the affected side. In delayed presentations, the entire hemiscrotum may be swollen, tender, and firm. The urine is usually clear with a normal urinalysis. In one-third of cases there is a peripheral leukocytosis.

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Emergency Department Treatment and Disposition

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Urologic consultation should be obtained immediately and preparations made to go to the operating room without delay. Doppler ultrasound or technetium scanning may be helpful if these procedures will not delay surgery. In the interim, detorsion may be attempted if the patient is seen within a few hours of onset: the affected testicle should initially be opened like a book, that is, the right testicle turned counterclockwise when viewed from below and the left testicle turned clockwise when viewed from below. Pain relief should be immediate. Decreased pain should prompt additional turns (as many as three) to complete detorsion; increased pain should prompt detorsion in the opposite direction. Ancillary studies should not delay operative intervention, since testicular infarction will occur within 6 to 12 hours after torsion.

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Figure 8.1.
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Testicular Torsion. Swollen, tender hemiscrotum, with erythema of scrotal skin and retracted testicle. (Photo contributor: Stephen W. Corbett, MD.)

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Figure 8.2.
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Bell-Clapper Deformity. A bell-clapper deformity in testicular torsion results from the twisting of the spermatic cord and causes the testis to be elevated, with a horizontal lie. The lack of fixation of the tunica vaginalis to the posterior scrotum predisposes the freely movable testis to rotation and subsequent torsion. An elevated testis with a horizontal lie may be seen in asymptomatic patients at risk for torsion.

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Figure 8.3.
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A and B Testicular Torsion. A retracted testicle consistent with early testicular torsion (minimal edema) is seen in both of these patients. A. (Photo contributor: David W. Munter, MD, MBA.) B. (Photo contributor: The Emergency Medicine Department, Naval Medical Center Portsmouth.)

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Figure 8.4.
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Testicular Torsion. Swollen, tender scrotal mass. (Photo contributor: Patrick McKenna, MD.)

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Pearls

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  1. The cremasteric reflex is almost always absent in testicular torsion.

  2. Patients may report similar, less severe episodes that spontaneously resolved in ...

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